ASSESSMENTSugesti Aliftitah S.Kep, Ns

What Is Assessment

the gathering of information about a patient's physiological, psychological,

sociological, and spiritual status.

Assessment consists of:

To be continue

What else????

Patients Identity• Name :• Age:• Sex:• Race:• Religion :• Education:• Occupation• Address• Marital status• Date of Interview

Chief Complaint

•The patient’s reason come to the clinic, as stated in their own words

•For example: I’ve got a nosebleed I blacked out I’ve lost my voice

History Of Present Illness

•Date and time of onset•Mode of onset•Precipitating or predisposing factors related to onset•Duration of onset•Other associated symptomp

Past nursing history

•History of contagious disease•Hereditary Disease•Allergic HistoryAdditional :ImmunizationsHistory of hospitalizations, surgery,

medications, etc

Family History

• Spesific to parent, siblings, grand parents, aunt, and uncle• Genogram

Vital sign

•T : Temperature•P: Pulse•R: Respiration•BP: Blood Pressure

Physical Examination• ROS (Review Of System)• B1: Breath• B2: Blood• B3: Brain• B4: Bladder• B5: Bowel• B6 : BoneAdditional:Psychososial assessment

Head To toe:1.Head 2.Ears 3.Nose 4.Mouth : teeth, tongue, lip5.Eyes6.Throat 7.Neck 8.Shoulders 9.Back 10.Arms/ hands11.Chest12.Stomach 13.Bowel/ bladder14.Genital organs 15.Legs 16.Feet 17.Skin 18.Sleep 19.Mental state

Example of Questioning ENT examination

1.Do you ever have nosebleed?2.Is there Any Bad Smell from your nose?3.Is there any discharge from your ears?4.Does it hurt when you swallow?

Respiratory examination1.Do you cough a lot?2.Do you ever get short of breath?3.Do you wheeze?4.Any pains in your chest when you cough?